Being Wrong - Kathryn Schulz [194]
“Observing more senior physicians.” Nancy Berlinger, After Harm: Medical Error and the Ethics of Forgiveness (The Johns Hopkins University Press, 2005), 41.
a 2002 survey of doctors’ attitudes. Berlinger, 2. The original survey is “Patients’ and Physicians’ Attitudes Regarding the Disclosure of Medical Errors,” JAMA, Vol. 289 (2003): 1001–1007.
To excuse their defensiveness and silence (FN). See Berlinger, especially Chapter Six, “Repentance.” The story of the Veterans Affairs Hospital in Lexington appears on pp. 69–70. A discussion of “I’m Sorry” laws appears on pp. 52–58. See also Doug Wojcieszak, John Banja, M.D., Carole Houk, J.D., “The ‘Sorry Works!’ Coalition: Making the Case for Full Disclosure,” Journal on Quality and Patient Safety, Vol. 32, No. 6 (June 2006): 344–350; and Kevin Sack, “Doctors Say ‘I’m Sorry’ Before ‘See You in Court,’” the New York Times, May 18, 2008.
“all the differing ways patients get hurt.” Krasner, “Hospital Aims to Eliminate Mistakes.”
Tenerife. The Tenerife accident has been widely written about. For a summary of the accident, see the Aviation Safety Network Accident Description at http://aviation-safety.net/database/record.php?id=19770327–0. For a detailed account, see the Netherlands Aviation Safety Board’s final report on the accident (one of the two planes involved was a KLM flight; hence the involvement of the Dutch authorities), Final Report and Comments of the Netherlands Aviation Safety Board of the Investigation into the Accident with the Collision of KLM Flight 4805, Boeing 747–206B, PH-BUF, and Pan-American Flight 1736, Boeing 747–121, N746PA, at Tenerife Airport, Spain, on 27 March 1977 (available online at http://www.project-tenerife.com/nederlands/PDF/finaldutchreport.pdf).
reducing significant commercial aviation accidents. National Transportation Safety Board Aviation Accident Statistics, Table 2: Accidents and Accident Rates by NTSB Classification, 1988–2007, 14 CFR 121 (available at http://www.ntsb.gov/aviation/Table2.htm). The National Transportation Safety Board divides accidents in commercial scheduled passenger service into “major” and “serious.” A major incident is defined as one in which either 1) an aircraft was destroyed, or 2) there were multiple fatalities, or 3) there was one fatality and the aircraft was substantially damaged. A serious incident means that either there was one fatality without substantial damage to the aircraft, or there was at least one serious injury and substantial damage to the aircraft. In addition to the drop in overall accident rates in commercial passenger service between 1998 and 2007, none of the accidents in 2007 were classified as major.
Six Sigma. Most of the background on Six Sigma is drawn from Peter S. Pande, Robert P. Neuman, Roland R. Cavanagh, The Six Sigma Way: How GE, Motorola, and Other Top Companies are Honing Their Performance (McGraw-Hill Professional, 2000). I borrowed (and tweaked) the 300,000 packages example from this book, where it appears on p. 12. My understanding of the “define, measure, analyze, improve, control” process was refined by Forrest W. Breyfogle’s Implementing Six Sigma: Smarter Solutions Using Statistical Methods (John Wiley and Sons, 2003).
“tolerance for failure”…“safe failure.” Pande et al., 17–18.
“the enemy” and “evil” (FN). Pande et al., 23.
crew and ground members are encouraged…to report mistakes. See the Aviation Safety Reporting System Immunity Policy, available online at http://asrs.arc.nasa.gov/overview/briefing/br_1.html. The ASRS